Maternal, Neonatal and Child Health Programmes ... - BRAC Research

Maternal, Neonatal and Child Health Programmes in Bangladesh Review of good practices and lessons learned

Hashima-e-Nasreen Senior Research Fellow, Research and Evaluation Division, BRAC [email protected]

Syed Masud Ahmed Research Coordinator, Research and Evaluation Division, BRAC [email protected]

Housne Ara Begum Assistant Professor, Institute of Health Economics, University of Dhaka

Kaosar Afsana Associate Director, Maternal, Neonatal and Child Health Programme BRAC Health Programme, BRAC [email protected]

July 2007 (Reprint – April 2010)

Research Monograph Series No. 32 Research and Evaluation Division, BRAC, 75 Mohakhali, Dhaka 1212, Bangladesh Telephone: (88-02) 9881265, 8824180 (PABX) Fax: (88-02) 8823542 E-mail: [email protected], Website: www.bracresearch.org

Copyright © 2010 BRAC First edition: July 2007 Reprint : April 2010

Cover design Sajedur Rahman Printing and publication Altamas Pasha Design and Layout Md. Akram Hossain

Published by: BRAC BRAC Centre 75 Mohakhali Dhaka 1212, Bangladesh Telephone: (88-02) 9881265, 8824180-87 Fax: (88-02) 8823542, 8823614 E-mail: [email protected] Website: www.brac.net/research

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TABLE OF CONTENTS

Acknowledgements List of abbreviations Executive summary Introduction Background Objectives Materials and methods

v vii xi 1 1 2 3

The country-specific context of maternal, neonatal and child health

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Demographic and socioeconomic profile Status of maternal health Status of child health Healthcare delivery system for maternal and child health

5 7 10 13

Policy-making in the health and population sectors Improving MNCH through health policy Major interventions on MNCH in Bangladesh MNCH interventions in the rural areas Introduction RH: MCH-FP services of the Government of Bangladesh Role of NGOs in MCH-FP programme MCH-FP project of ICDDR,B at Matlab MCH-FP extension project BAMANEH’s MCH Project Birth and re-birth knowledge from BRAC Emergency obstetric care in rural Bangladesh Safe deliveries by skilled attendants Menstrual regulation programme in Bangladesh Child health interventions in Bangladesh The Saving Newborn Lives (SNL) Programme Kangaroo Mother Care (KMC) Programme USAID funded programme

16 16 19 20 20 21 25 25 26 27 29 32 36 39 42 43 45 46

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MNCH interventions in the urban areas Introduction Urban RH: MCH-FP initiative First urban primary health care project (UPHCP-I) Second urban primary health care project (UPHCP-II) The NGO service delivery programme Urban community health programme of Gonoshahthya Kendra Child survival programme of CONCERN Bangladesh Dustha Shasthya Kendra BASIC I country programme: Bangladesh EngenderHealth (Bangladesh) UNFPA supported programme

49 49 50 52 54 55 57 59 60 62 63 64

Gaps and Barriers

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Best practices and lessons learned

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Implications and recommendations

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References

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ACKNOWLEDGEMENTS We are grateful to all stakeholders of different organizations who provided us with necessary information, papers, documents and reports and thus helped us prepare this review. The support and cooperation of Dr. Imran Matin, Director, Research and Evaluation Division, BRAC is gratefully acknowledged. We are thankful to Dr. Marge Koblinsky, the scientist of ICDDR,B and Professor Sadiqa Tahera Khanam, formerly Director, NIPSOM, for reviewing the report. Sincere thanks to Mr. Hasan Shareef Ahmed for editing the manuscript and to Ms. Nuzhat Chowdhury for checking the acronyms and references of the document. Thanks are also due to Mr. Syed Suaib Ahmed for logistic and management support. We are grateful to BRAC for giving us the opportunity to conduct this study. BRAC is supported by countries, donor agencies and others who share its concerns to have a just, enlightened, healthy and democratic Bangladesh free from hunger, poverty, environmental degradation and all forms of exploitation based on age, sex, religion, and ethnicity. Current major donors include AGA Khan Foundation (Canada), AusAID, CAFAmerica, Campaign for Popular Education, Canadian International Development Agency, Columbia University (USA), Danish International Development Agency, DEKA Emergence Energy (USA), Department for International Development (DFID) of UK, Embassy of Denmark, Embassy of Japan, European Commission, Fidelis France, The Global Fund, The Bill and Melinda Gates Foundation, Government of Bangladesh, Institute of Development Studies (Sussex, UK), KATALYST Bangladesh, NORAD, NOVIB, OXFAM America, Oxford Policy Management Limited, Plan International Bangladesh, The Population Council (USA), Rockefeller Foundation, Rotary International, Royal Netherlands Embassy, Royal Norwegian Embassy, Save the Children (UK), Save the Children (USA), SIDA, Swiss Development Cooperation, UNDP, UNICEF, University of Manchester (UK), World Bank, World Fish Centre, and the World Food Programme.

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LIST OF ABBREVIATIONS AFP ADB ADF AHI AIDS ANC APR ARH ARI BAMANEH BAVS BCC BCCP BCG BDHS BINP BPASA BRAC BWHC CDD CDRS CEDAW CHW CKMC CNP CPR CRC CRHCC CWFP DCC DDFP DFID DGFP DGHS DPT DSK EHC EOC ENC

Acute Flaccid Paralysis Asian Development Bank Asian Development Fund Assistant Health Inspector Acquired Immunodeficiency Syndrome Anti-Natal Care Annual Programme Review Adolescent Reproductive Health Acute Respiratory Infections Bangladesh Association for Maternal and Neonatal Health Bangladesh Association for Voluntary Sterilization Behaviour Change Communication Behaviour Change Communication Programme Bacilli Calmette Guerin Bangladesh Demographic and Health Survey Bangladesh Integrated Nutrition Programme Bangladesh Association for Prevention of Septic Abortion Building Resources Across Communities Bangladesh Women’s Health Coalition Control of Diarrhoeal Diseases Client Data Recording System Convention on the Elimination of all forms of Discrimination Against Women Community Health Worker Community-based Kangaroo Mother Care Community-based Nutrition Promoters Contraceptive Prevalence Rate Convention on the Rights of the Child Comprehensive Reproductive Health Care Center Concerned Women for Family Planning Dhaka City Corporation Deputy Director –Family Planning Department for International Development (UK) Directorate General of Family Planning Directorate General of Health Services Diphtheria-Pertussis-Tetanus Dustha Shasthya Kendra Essential Health Care Emergency Obstetric Care Essential Newborn Care

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EPI ESP FFYP FP FP-FP FPA FPI FWA FWV GK GoB HA HAP HDI HFWC HI/SI HIV HKI HNP HNPSP HPSP HPSS IAMANEH ICDDR,B ICPD IDA IEC IMCI IPHN i-PRSP IUD KMC LBW LGD MA MCH-FP MCHTI MCWC MDG M&E MFSTC MIS MMR

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Expanded Programme on Immunization Essential Service Package Fifth Five-Year Plan Family Planning Family Planning Facilitation Programme Family Planning Assistant Family Planning Inspector Family Welfare Assistant Family Welfare Visitor Ganoshasthya Kendra Government of Bangladesh Health Assistant Hospital Action Plan Human Development Index Health and Family Welfare Centers Health Inspector/Sanitary Inspector Human Immunodeficiency Virus Helen Keller International Health Nutrition and Population Health Nutrition and Population Sector Programme Health and Population Sector Programme Health and Population Sector Strategy International Association for Maternal and Neonatal Health International Centre for Diarrhoeal Disease Research, Bangladesh International Conference on Population and Development International Development Agency Information Education Communication Integrated Management of Childhood Illnesses Institute of Public Health Nutrition Interim Poverty Reduction Strategy Paper Intra Uterine Device Kangaroo Mother Care Low Birth Weight Local Government Division Medical Assistant Maternal and Child Health- Family Planning Maternal and Child Health Training Institutes Maternal and Child Welfare Centre Millennium Development Goals Monitoring and Evaluation Mohammadpur Fertility Services and Training center Management and Information System Maternal Mortality Rates

MNH MOLGRD&C MO MOHFW MR MRTSP NGO NID NIPHP NIPORT NMR NNP NSDP NSP NSV Obs/Gynae ORS PA PHC PIP PSTC PNC QIP QOC HCC RHDP RSDP RH-STEP RMO RTI SBA SNL Sr. FWV SSC STI TBA TTBA TCC TFR TT TV UCHP UFPO UFHP

Maternal and Newborn Health Ministry of Local Government, Rural Development and Cooperatives Medical Officer Ministry of Health and Family Welfare Menstrual Regulation Menstrual Regulation Training and Services Programme Non-Government Organization National Immunization Day National Integrated Population and Health Programme National Institute of Population Research and Training Neonatal Mortality Rate National Nutrition Programme NGO Services Delivery Programme Nutritional Surveillance Project No Scalpel Vasectomy Obstetric and Gynaecology Oral Rehydration Solution Partnership Agreement Primary Health Care Project Implementation Plan Population Services and Training Centre Post-Natal Care Quality Improvement Partnership Quality of Care Reproductive Health Care Center Reproductive Health and Disease Control Programme Rural Service Delivery Programme Reproductive Health Services Training and Education Programme Resident Medical Officer Reproductive Tract Infection Skilled Birth Attendant Saving Newborn Live Senior Family Welfare Visitor Support Services and Coordination Sexually Transmitted Infection Traditional Birth Attendant Trained Traditional Birth Attendant Training Coordination Committee Total Fertility Rate Tetanus Toxoid Training and Visit Urban Community Health Programme Upazila Family Planning Officer Urban Family Health Partnership

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UHC UHFWC UHFPO UNDP UNFPA UNICEF UPHCP USAID VHPC WHDP WHO WRLH

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Upazila Health Complex Union Health and Family Welfare Centre Upazila Health & Family Planning Officer United Nations Development Programme United Nations Population Fund United Nations Children’s Fund Urban Primary Health Care Project United States Agency for International Development Village Health Post Committee Women’s Health and Development Programme World Health Organization Women's Right to Life and Health

EXECUTIVE SUMMARY Bangladesh has achieved substantial gains in the field of health during the last three decades despite modestly declining poverty and inadequate health services. However, Infant Mortality Rate (IMR) and maternal mortality ratio (MMR) continue to be unacceptably high compared to many other developing countries, with persisting socioeconomic differentials. While access to family planning is increasing, access to three other pillars of safe motherhood namely antenatal care, clean and safe delivery, and essential obstetric care, remain largely unfulfilled. The objective of this study is to review the major maternal, neonatal and child health (MNCH) interventions since independence for documenting best practices, revisiting lessons learned and identifying gaps for informed programme design in future. This review is based on secondary data on MNCH interventions, and face-to-face interviews with key informants from different organizations implementing MNCH programmes. Both published and unpublished materials for the last ten years were selected which include materials on relevant health systems and interventions in the public and private sectors. While searching the website, key words such as maternal, child, neonatal, health, intervention, programmes, health status, traditional birth attendants (TBAs), midwives, Bangladesh, and emergency obstetric care (EmOC) were used. In-depth interviews were conducted with 10 stakeholders in different national and international organizations who are involved in planning, policy making and implementing MNCH interventions at local and national levels. The interviews focused on intervention components, strategies, targeted populations, expected outcomes, achievements so far and strengths and weaknesses of their programme. Data were collected during February-March 2006. Findings were organized separately for rural and urban areas respectively. The rural scenario To address the poor state of MNCH the government of Bangladesh has undertaken several initiatives since independence. In order to detect and refer complicated cases, the EmOC programme was undertaken in early 1990s and the rights-based comprehensive National Maternal Health Strategy was adopted in 2001. The strategy has been integrated into the Health and Population Sector Programme (HPSP 1998-2003) and the Health, Nutrition and Population Sector Programme (HNPSP 2004-2011). It provides essential services package comprising family planning and safe motherhood services, and adolescent and child care services at

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Primary Health Care (PHC) level through domiciliary and facility-based service delivery points. Several bilateral agencies (UNICEF, UNFPA, WHO, EU, etc.) and non-government organizations (NGO) (BRAC, CARE Bangladesh, BPHC, EngenderHealth, ICDDR,B, NSDP, PSTC, etc.) are providing hospital or community-based services or both in order to supplement and complement government’s initiatives in this field. Public MCH-FP service provision in Bangladesh has a number of distinguishing features. The pattern of service utilization is lopsided with low utilization of most facilities at the community level (upazila and below), and over utilization at the district and at teaching hospitals. The major reason for low utilization of primary level facilities is the poor service quality and negative perception of the community about the types of services available. Though the government EOC project has proven as an effective way of improved services for maternal care by using three delays model, not even the district hospital is fully capable of providing it in an effective manner. Study findings from the Malab MCH-FP project show that family planning programme can be successful even under unfavorable socioeconomic conditions. The client-oriented services were also reported to be successful in reducing maternal mortality rates in the project areas. This is characterized by the presence of local female community health workers with 8-10 years of education and backed by a well developed support system of female paramedical and medical staff, and intensive field supervision. Given the basic training in household communication, family planning service techniques and supportive supervision, female workers could interact effectively with their village clientele. In addition, an organizational culture based on qualification and performance with quality of care has succeeded in raising the performance to levels much higher than those of the government programmes. Thus, the combined efforts of community sub-centre midwives, trained physicians at the Matlab maternity clinic, functional referral chain and proper transport arrangements have contributed to the reduction of maternal mortality in Matlab. The adaptation of Matlab model to the public sector has produced a new model of services in project areas that attempts to address some of the problems of the public sector. Most government training programmes have attempted to improve the level of knowledge and skills of the TBA but have done little to bridge the wide socio-cultural gap between the traditional and the modern practitioners. On the other hand, several micro-level projects especially in the NGO sector have shown that when this gulf between the TBA and the formal health system is bridged, TBA training programmes can be much more effective. In the foreseeable future, they will continue to play a significant role until there is sufficient infrastructure to make high quality institutional delivery affordable and accessible to all women.

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Although the two skilled birth attendants (SBA) models using community midwives in Chandpur (BAVS) and Chakaria (ICDDR,B) differ in their organization and implementation, they have independently shown promising results. However, they have only been tried to a limited extent. Also, issues of linkage with formal healthcare systems and sustainability questions should be addressed before scaling up these models. Fertility decline of high-risk groups and use of safe menstrual regulation (MR) provided by the government undoubtedly also contribute to the reduced MMR. Many women in Bangladesh now enjoy access to menstrual regulation (MR) services to avoid unwanted pregnancies. Though studies on MR have found it to be generally safe, it raised concerns regarding the technical training and skills of the service providers. Approximately 71,800 women are hospitalized each year due to complications from unsafe procedure. Access to legal MR services is also poorer in rural areas than in the urban areas. Improved quality, accessibility, capacity building of providers, ensured supplies and advocacy are issues to be addressed rather than legality of abortion. Besides, Expanded Programme on Immunization (EPI) and fertility regulation activities, Integrated management of Childhood Illnesses (IMCI) is also playing an important role in child survival through reducing child mortality and morbidity and promoting child growth, development and healthy practices. Effective implementation of IMCI case management guidelines improved quality of care in health facilities across various settings in Bangladesh. Considering its impact at a low cost, government plans gradual expansion of IMCI programme in the country. How well IMCI can work depends upon the strength of the health system responsible for its implementation. However, health system support for IMCI rarely reached adequate levels in Bangladesh. Intra-partum, post-natal and neonatal cares have the potential to save 20-40% of newborn lives. However to date, post-natal care for mothers and newborns has received relatively little emphasis in public health programmes in Bangladesh, with only a tiny minority of mothers and babies in high-mortality settings receiving post-natal care. Care at birth and in the first days of life not only saves the lives of mothers and newborns, but also reduces serious complications that may have longterm effect. The Saving Newborn Lives (SNL) initiative demonstrated remarkable changes in all areas of maternal and newborn care, albeit still low. There are controversies and challenges with the effectiveness of Kangaroo Mother Care (KMC) in reducing infant mortality. But KMC is at least as safe and effective as traditional care with incubator especially for the LBW infants who are unable to regulate their temperature, or may be associated with reduction of many neonatal infections. Moreover, as the

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community-based KMC increases exclusive and predominant breastfeeding, the method would be expected to reduce the incidence of diarrhoea and possibly growth of neonate. Recently, the Population Council, BRAC and Mitra and Associates have conducted a communitybased randomized control trial, the result of which is expected to design intervention strategies for rural communities in Bangladesh. Considerable progress was achieved by the USAID-funded projects in expanding access to MCH services through capacity development of partner NGOs, quality assurance in service delivery, and unified logistics and supplies at local level. Project activities demonstrated that ensuring availability of integrated health, family planning, and MCH services through traditional service provision system could make changes in the lives of the mother and children. The urban scenario The urban population in Bangladesh is growing fast, at an annual rate of 6% (compared to national average around 2%). A major consequence of the surge in urban population is the rapid growth of slums and squatter settlements. While the urban poor population is not confined to slums, these do present an aggregation of the poorest section of the urban population. Due to overcrowded, unsanitary and sub-standard dwellings, then are thus at high risk of contracting communicable diseases. Urban health services have been the responsibility of the Ministry of Local Government, Rural Development and Cooperatives (MOLGRD&C) implemented through the city corporations and the municipalities. But due to limited resources and manpower, public sector health services could not keep up with increasing needs. The primary health care programme in urban areas began to improve after 1997, when the urban family health partnership (UFHP) project launched with the financial support form the USAID under the National Integrated Population and Health Programme (NIPHP). Thereafter in 1998, the government of Bangladesh and the Asian Development Bank (ADB) initiated the Urban Primary Health Care Project (UPHCP) in 1998. This project is implemented through the Local Government Division (LGD) of the MOLGRD&C and 4 city corporations, and supported contracting of NGOs to provide urban health services for the poor. After successful completion of the first phase in 2005, the project is now undergoing its second phase. Under the UPHCP, packages of high-impact primary health care services are provided to the urban population, particularly poor women and children. These are complemented by a project for reproductive health services in metropolitan cities jointly funded by UNFPA, ADB and the Nordic Development Fund, which upgraded city corporation maternity centres

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for comprehensive EOC, family planning, and RTI/STI (Reproductive Tract Infection/Sexually Transmitted Infection) detection and treatment. Other major providers of primary and secondary level healthcare in the urban areas are: NGO Service Delivery Programme (NSDP), Gonoshasthya Kendra (GK), Dustha Shasthya Kendra (DSK), Concern (Child Survival Programme), Bangladesh Women’s Health Coalition (BWHC), Marie Stopes, BASICS, and EngenderHealth. The lowest tier of service delivery in the urban areas was doorstep delivery provided by the government and NGO fieldworkers. Currently, the doorstep services have been withdrawn by the NGOs and shifted toward static service-delivery sites. The fixed sites at the lowest tier are the satellite clinics organized by NGOs on once a month basis. The next tier of service delivery comprises clinics/dispensaries managed by the NGOs, GoB, DCC and the private sector. Most of them are staffed with paramedics and/or qualified physicians, and very little coordination and referral systems exist among them. Best practices and lessons learned Public MCH-FP service provision in Bangladesh has a number of distinguishing features. First, the pattern of service utilization is unbalanced, with low utilization of most facilities at the community level (upazila and below) and over utilization of facilities at the district and at teaching hospitals. Though the government EOC project has been proven as an effective way of maternal care by using three delays model, none even the district hospital is able to provide it. Upgrading the quality and coverage of safe motherhood services at formal facilities to ensure 24hour EOC may have the largest payoff in averting deaths and reducing disability in women and children in Bangladesh. Study findings from Malab MCH-FP interventions demonstrated that family-planning programme can be successful even under unfavorable socioeconomic conditions. Particularly critical to the success of the Matlab experiment is the client-oriented services delivered through the female community health workers (CHW), with supportive supervision. In addition, experiences from the project suggest that the introduction of an organizational culture based on qualification and quality of care has succeeded in raising the performance of the CHWs to levels much higher than those of the Government program. The pattern of self-referral in Matlab MCH-FP areas strongly suggests that if quality emergency obstetric services are available, substantial numbers of people will use them, even in the absence of community interventions encouraging use. The design of the BRAC’s programme was based on comprehensive primary health care model. It was structured in a way to be integrated with the rural development programme and the non-formal primary

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education programme, as BRAC believes addressing health and development issues holistically. Shasthya Shebikas or Community Health Volunteers are at the core of BRAC’s health interventions, including MNCH interventions. The latter programme is designed based upon BRAC’s long experiences in the MCH areas (e.g., Women’s Health and Development Programme (WHDP) and integrates MCH activities with interventions aimed at saving the lives of neonates through communitybased interventions. Considerable progress was achieved by the USAID funded projects in expanding access to MCH services through capacity development of partner NGOs, quality assurance in service delivery, and unified logistics and supplies at local level. These projects showed that emphasis need to be put on health and family-planning infrastructure and staff, improving service quality, involving traditional health system, and changing attitudes and behaviours with respect to service utilization among potential clients. Though there is an increasing trend for the proportion of births delivered by the SBA, still three-fourth of the births are assisted by the TBAs. Most government TBA training programmes have attempted to improve their level of knowledge and skills but have done little to bridge the wide sociocultural gap between the traditional and the modern practitioners, and met with limited success. On the other hand, several micro-level projects especially in the NGO sector have shown that when this gulf between the TBA and the formal health system is bridged, TBA training programmes can be much more effective. In the foreseeable future, they will continue to play a significant role until there is sufficient infrastructure to make high quality institutional delivery affordable and accessible to all women. Several community-based SBA pilots of the government and others (e.g., Chakaria community-based midwifery project, Chandpur community mid-wifery project) worked with trained mid-wives and were found to be successful in raising skilled birth attendance. These SBAs are trained for providing clean home delivery services, recognizing danger signs and mobilizing community support for those women who are unable to go for institutional delivery. Intra-partum, post-natal and neonatal cares have the potential to save 20-40% of newborn lives. Care at birth and in the first days of life not only saves the lives of mothers and newborns, but also reduces serious complications that may have long-term effect. The SNL (Saving Newborn Lives) initiative demonstrates remarkable changes in all areas of maternal and newborn care. Training CHWs in Essential Newborn Care (ENC) has increased the proportion of women receiving early ante- and post-natal care. Trained TBAs are important providers of delivery and PNC services in the community. However, they need regular monitoring and supervision. Experience from pilot studies in Bangladesh suggest

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integrating Kangaroo Mother Care (KMC) with the post-natal care services to enable regulation of body temperature of the low birth weight (LBW) infants weighing 2000 g or less. The most dramatic achievement in child health has been children’s immunization, which has greatly augmented the chances of their survival. IMCI strategy offers a promising set of interventions to address the child survival problems in Bangladesh. Effective implementation of IMCI case management guidelines improved quality of care in health facilities across various settings. How well IMCI can work depends upon the strength of the health system responsible for its implementation, which rarely reached adequate levels in Bangladesh. The Bangladesh Urban Primary Health Care Project (UPHCP) targets primary health care services in urban areas of Bangladesh where the government contracts NGOs to provide services. Involving NGOs for providing healthcare through clinics run by city corporations yielded a landmark policy success in establishing GO-NGO collaboration in healthcare service provision. NSDP (NGO Service Delivery Programme) has demonstrated solid progress in expanding essential family planning and health services to about 20 million urban and rural poor in six divisions of Bangladesh. There are other projects in urban areas by various NGOs (e.g., GK, DSK, SHAHAR, CONCERN Bangladesh, BWHC, EngenderHealth etc.) who experimented with different innovative approaches to provide quality services to the poor. Conclusion Taking experiences of low resource setting into account, upgrading the quality and coverage of safe motherhood services (including neonatal care) will have the largest payoff in averting deaths and reducing disability among women and children in Bangladesh. For scaling up of these tasks, building a functioning primary healthcare system from community level to the first referral-level facilities is essential. Particular emphasis should be placed on developing human resources for health (HRH) in this sector, e.g., the trained TBAs/midwives for skilled assistance during delivery at home and community health volunteers/ workers for raising awareness, motivation, neonatal and IMCI care, etc. Coverage of essential obstetric care should be made universal and functional at the sub-district and the district level. The public and the private sectors, especially the not-for-profit NGOs and local level clinics, should come together in effective partnerships in this endeavour.

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INTRODUCTION Background Bangladesh has seen impressive achievements in maternal and child health (MCH) in the past three decades, thanks to the success of targeted public health and education interventions and investments. Such interventions include immunization, family planning, nutrition supplementation, the national oral rehydration solution (ORS) programme, stipend and other support for female education, and increased public expenditure on health (from 0.7% of GDP in 1990 to 1.5% in 1999-2001) and education (from 1.5% of GDP in 1990 to 2.3% in 1999-2001). However, indicators related to safe motherhood suggest that the progress has been slow in crucial areas of reproductive health. Infant (IMR), neonatal (NMR) and maternal (MMR) mortality continue to be unacceptably high compared to many other developing countries, with persisting socioeconomic differentials. (NIPORT, ORC Macro, John Hopkins University, ICDDR,B 2003). Bangladesh is also a poor performer with respect to skilled attendance at birth and essential obstetric care. While access to family planning is increasing, access to the three other pillars of safe motherhood namely antenatal care, clean and safe delivery, and emergency obstetric care (EOC) remain largely unfulfilled (NIPORT, ORC Macro, John Hopkins University, ICDDR,B 2003). Whatever government health facilities are available at various levels, these are not adequately utilized (UNDP 2004). Women’s movements like International Conference on Population and Development (ICPD) in Cairo and Women’s conference in Beijing sought to mainstream reproductive health and gender issues in the development discourse to establish women’s rights, ameliorate their poor health status and to empower them (International Conference on population and Development, 1994; Beijing declaration and Platform for action, 1995). On the other hand, the Child Survival Revolution, the World Summit for Children, the Child Right Movement and the United Nation’s ‘The World Fit for Children’ give priority to child health committing to reducing under-five mortality (Child Survival Partnership 2004). More recently, the UN calls for achieving the Millennium Development Goals (MDG) (Table 1) by 2015 with special attention to the reinforcement of safe motherhood initiatives and child survival programmes (The United Nations Millennium Goals 2000). In response to the prevailing state of maternal, neonatal and child health, the government of Bangladesh has taken a sectorwide approach (SWAP)

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together with poverty reduction strategies to focus on maternal and child health, for attaining the MDGs (Ministry of Health and Family Welfare 2003; Planning Commission, GOB 2004). Keeping pace with the MDG targets and the national strategies, different governmental and nongovernmental organizations (NGO), bilateral agencies and donors have been implementing health interventions individually or in partnership with government to reduce maternal, neonatal and child mortality, particularly amongst the poor. BRAC, the largest NGO in the world (www.brac.net) is also not lagging behind. Consolidating more than 30 years of experience in health interventions, BRAC Health Programme (BHP) has launched a comprehensive maternal, neonatal and child health (MNCH) programme, customized for rural and urban slum populations. Table 1. Millennium development goals for maternal and child health Health targets

Health indicators

Goal 4: Reduce child mortality Target 5

Reduce by two third, between 1990 and 2015, the under-five mortality rate

13. Under five mortality rate 14. Infant mortality rate 15. Proportion of one-year-old children immunized against measles

Goal 5: Improve maternal mortality Target 6

Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

16. Maternal mortality ratio 17. Proportion of births attended by skilled health personnel

Source: World Health Organization 2005. MDG Health and Millennium Development Goals. p11 (MDG 2005).

As a prologue to these activities, the Research and Evaluation Division of BRAC (www.bracresearch.org) has carried out a review of the existing MNCH programmes in Bangladesh undertaken by the government, NGOs and private sectors to identify best practices and the factors behind successes and failures, thereby pinpointing gaps and challenges. This provides an evidence base to develop informed intervention components, approaches and strategies for the MNCH initiatives in the country and endow with directions for future advocacy efforts. Objectives The objective of this review is to map the programmatic landscape by documenting best practices, revisiting lessons learned, and identify gaps for informed programme design in future. Thus, the review particularly focused on:

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1. 2. 3. 4.

The current state of maternal, neonatal and child health (MNCH); The existing MNCH programmes with regard to the intervention components, coverage, responsiveness and achievements; Best practices and lessons learned; Implications for future programme design.

Materials and methods This review is based on available secondary materials on MNCH-related issues, and where deemed necessary, face-to-face interviews with key informants from different organizations implementing MNCH programmes. Review The main method followed for this review included searching by snowballing and pubmed, collecting and reviewing published and unpublished materials on MNCH interventions. Recent evaluations and relevant documentations of different MNCH programmes were also consulted. Around 100 published articles from books, booklets, journals, reports, leaflets and web pages were reviewed. Both published and unpublished materials for the last ten years were selected including materials on relevant health systems and interventions in the public, not-for-profit non-governmental and for-profit private sectors. While searching the web, key words such as maternal, child, neonatal, health, intervention, programmes, health status, Bangladesh, and EOC were used. Qualitative interviews with stakeholders We identified 13 national and international agencies including UNICEF, NGO Service Delivery Programme (NSDP), Urban Primary Health Care project (UPHCP), Bangladesh Association for Voluntary Sterilization (BAVS), Bangladesh Association for Maternal and Neonatal Health (BAMANEH), ICDDR,B, IPHN, BRAC, Bangladesh Women’s Health Coalition (BWHC), Concern Bangladesh, BASICS, Gonoshasthya Kendra (GK) and CARE Bangladesh for stakeholders’ interviews. These agencies contribute significantly in the improvement of MNCH, have had wider coverage and sustainable programmes in Bangladesh. In-depth interviews were conducted with 10 stakeholders who have been involved in planning, policy-making and implementing MNCH interventions at local and national level. The interviews focused on intervention components, strategies, targeted populations, expected outcome, achievements so far and strength and weakness of their programme. Data were collected during February-May 2006.

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Data analysis and report The interviews were coded line by line and categories were identified. Analysis was done under the themes of current states of MNCH; status of existing MNCH interventions vis-à-vis intervention components, relevance on policy, achievements so far and responsiveness; best practices; lessons learned; and directions for future planning.

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THE COUNTRY-SPECIFIC CONTEXT OF MATERNAL, NEONATAL AND CHILD HEALTH This section contexualizes the present states of the MNCH situation in Bangladesh. It considers a range of historical, demographic, economic, socio-cultural and behavioural factors influencing MNCH programmes. The subsequent sections of the review are informed and analyzed in relation to this section. Demographic and socioeconomic profile Poverty Bangladesh is one of the most densely populated country with a land mass of 147,570 sq. km and a population of more than 140 million, 70% of whom live in rural areas (BDHS 2004). The population growth rate is 1.7% per annum and it ranks 139th position (out of 173 countries) in UNDP’s Human Development Index (HDI) with an estimated per capita GDP of US$ 1,900 of which 22% is generated by agriculture (UNDP 2005). According to UNDP, around 83% of the population live on less than US$ 2 a day and 36% on less than US$ 1 a day. Through continuous effort of the government and the non-government sectors, income poverty has declined from an estimated 58% of the population during 1983-84 to just below 50% in 2000 with one percent reduction every year (GoB 2004). Access to education The adult literacy rate in 2004 was 49.6% with 55.5% for males and 43.4% for females (BBS 2004). Although the female/male ratio in primary school was 100:115, in secondary schools and universities this gap increased to 100:131 and 100:322 respectively (Ministry of Education 2002). In addition to gender inequalities, inequalities also exist by geographical areas. Only 36% of the rural women are literate, compared to 60% of urban women. However, this situation is rapidly changing in recent years. Now the net enrolment of female students has surpassed males at both the primary and secondary levels (UNICEF 2007). This is because the government has a ‘food for education’ programme, which provides wheat to female students, and at secondary level, another programme provides scholarships to girls (UNICEF 2000). NGOs, meanwhile, have established

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non-formal education programmes, concentrating on children 8-15 years with a special emphasis on girls. Gender relations and status of women Despite some progress in ranking of HDI, the status of women still remains low. The UNDP gender-related development index (GDI) ranks Bangladesh very low, at 105th position (out of 146 countries) (2003). It implies social inequalities i.e. inequalities in income and education between men and women (Country Menu 2003). Women experience greater deprivation and vulnerability due to their subordinate position and low status in the society with patriarchal value system. Women are largely involved in the informal sector and subsistence activities. Violence against women in the form of rape, assault, trafficking and acid throwing is prevalent (UNICEF 2000; UNFPA 2003). Gender-based violence in the country aggravates the built-in gender discrimination. Several measures have been adopted to safeguard women’s legal rights. For instance, special initiatives like girls’ stipend, free schooling for girls, and food for education, etc. have been undertaken to increase enrollment. Despite these provisions, loopholes in the existing laws, and lack of proper implementation are some of the impediments encountered. Women’s participation at the policy-making level and politics is still very low. Few women hold high positions in the government and private sector. Bangladesh however has a gender strategy, which is based on the National Policy and Action Plan on Women, coordinated by the Ministry of Women and Children’s Affairs (ADB 2001). Women in Bangladesh have to continue to fight for basic rights and status in terms of political participation, education, healthcare (specially reproductive and sexual health), labour force participation, mobility, food security, freedom from violence and the recognition and respect for their sexuality. Demographic and health indicators Although there has been considerable improvement in the health indicators, still more than 60% of the population has very little access to basic healthcare (MOHFW 2003). The number of qualified physicians and nurses in Bangladesh is quite low, compared to other low-income counties (Cockcroft et al. 2004). Around 26% of professional posts in rural areas remain vacant (Chaudhury and Hanner 2003). Despite modestly declining poverty and inadequate health services, Bangladesh has achieved substantial gains in the field of health in the three decades since independence in the ‘70s (GoB 2004; Mahmud 2004), as evidenced in mortality and fertility declines in this low income country compared to other South Asian countries.

6

Over the last three decades, Bangladesh has undergone remarkable improvements in social indicators (life expectancy at birth to 64.9 years in 2005, among others) and graduated to the ‘medium human development’ group of countries (UNDP 2004). The value of HDI for Bangladesh increased at an average rate of 8.8% per annum during the 1990s, the fastest growing HDI in South Asia (BDHDR 2000). These data suggest that Bangladesh is favourably placed to achieve the MDGs related to health and education. About a quarter of the population consists of adolescents and youths. Some of the problems concerning adolescents include early age at marriage, high fertility and low levels of secondary and tertiary education. The higher death rate among girls compared to boys aged 1519 (1.81 as against 1.55 per 1,000 population) is mainly due to maternal causes. Access to appropriate reproductive health information and services for this group is inadequate. Status of maternal health Although improving, in terms of national averages, maternal health status for many Bangladeshi women remains poor. Around 50% of Bangladeshi women were found to be chronically malnourished with a body mass index less than 18.5. Over 43% of pregnant women were iodine deficient and more than 2.7% developed night blindness during pregnancy (BDHS 2001). Despite very low levels of the use of antenatal and skilled delivery services, the situation with respect to Tetanus Toxoid (TT) vaccination among women was found satisfactory in 2004, with 2 in 3 women receiving two doses of tetanus toxoid and 21% receiving one dose, a 19% improvement since 1995-1999 (BDHS 2004). Due to past efforts of both the government and the development partners, the total fertility rate (TFR) has declined from 6.3 in 1975 to 3.0 in Causes of maternal mortality per 2004, coinciding with 1000 impressive increases in the 0.105 x Haemorrhage contraceptive prevalence rate 0.088 x Eclampsia (CPR) from 9.6% in 1975 to 0.018 x Abortion 58% in 2004 (BDHS 2004). Maternal death

x x x x x x x

Sepsis Obstructed labour Other obstetric causes Anemia Cardiovascular causes Respiratory causes Unspecified

0.013 0.019 0.11 0.014 0.002 0.013 0.026

The maternal mortality ratio (MMR) in Bangladesh has declined from nearly 574 per 100,000 live births in 1990 to Source: BMMS, 2003 between 320 and 400 in 2004 (NIPORT 2001; BDHS 2004). Considering the trend, maternal health status is apparently approaching the targets set for the MDGs. Despite

7

this progress, at present about 12,000 women die each year from maternal causes. The estimated lifetime risk of dying from pregnancy and child birth-related causes in Bangladesh is about 100 times higher than that in developed countries (NIPORT 2003). A tragic consequence of these deaths is that about 75% of the babies born to these women are also likely to die within the first week of their life (WHO 2004). Causes of maternal death Maternal death is caused by direct, indirect and other related factors. The major direct causes of maternal deaths in Bangladesh are postpartum haemorrhage, eclampsia, complications of unsafe abortion, obstructed labour, postpartum sepsis, and violence and injuries (Fauveau 1994, NIPORT et al. 2003, MOHFW 2003). About one-fourth of the total maternal death in rural Bangladesh is due to unsafe abortion and related complications (Alauddin 1986; MOHFW 2003). However, a recent survey found this proportion to be lower (NIPORT et al. 2003). Unmarried women accounted for 36% of all complications of induced abortion e.g., sepsis (Fauveau et al. 1991). Percentages of maternal death from eclampsia varies from 12 to 53% in different studies (Fauveau et al. 1994). Haemorrhage comprises 20 to 29% of all direct obstetric causes (Fauveau et al. 1994; NIPORT, Mitra and Associates & Macro International Inc, 2003). Death due to obstructed labour varies from 6.5 to 17% which comprises complications of malpresentation, cephalopelvic disproportion, inability to expel fetus, retained placenta (Fauveau et al. 1994; Khan et al. 1985). Around 14% of deaths of pregnant women are associated with injury and violence (WHO 2004). Different studies identified a number of indirect causes of maternal death in Bangladesh, such as anaemia, malaria, tuberculosis, etc. The risk factors for maternal mortality include women's low status in society, poor quality of maternity care services, lack of trained health professionals, lack of EOC services, low uptake of services by women, infrastructure and administrative difficulties (Haque et al. 1997; Streatfield et al. 2003). Sometimes distance of the health service facility from home and lack of transportation facilities in rural area act as obstacles to seeking care (NIPORT, Mitra and Associates, & Macro International Inc. 2003). Early childbearing is another important risk factor for maternal death. MMR is much higher among females aged 15-19 years (7.3% 1,000 live births) compared to those in the low-risk age group of 20-34 years (4.3 per 1,000 live births) (WHO, 2004). Approximately, half of women marry under the age of 18 and 58% become mother of first child under the age of 20 (BDHS 2004). Inadequate financial resource is a prominent barrier in meeting the MDGs. Only 6.9% of the total budget is allocated for expenditure in

8

health sector. In 1998 the total government health expenditure per capita was US$4 only (NIPORT, Mitra and Associates and ORC Macro 2005). Referral system for obstetric emergencies is non-existent or very weak in rural area due to the lack of second level facilities and trained staff to handle them. The GoB has a maternal health strategy which is rolling out nationally. The suggested strategy for developing comprehensive EOC in public facilities is still lower than the actual need. Most functional health facilities do not have sufficient essential drugs to meet actual needs, since the budgetary allocation for the procurement of drugs is very small. In 1997, a sample of remote health facilities revealed that only 8% of essential drugs needed at those levels were available (UNICEF/WHO 1997). In Upazilla level, the qualified medical doctors (MBBS) are posted, but obstetric first aid is virtually absent at that level (UNICEF/WHO/UNFPA 1996). Service utilization To improve the health status of mothers, ante-natal, delivery and postnatal care from skilled providers is important. This section explores the state of service utilization by mothers during ante-natal, delivery and post-natal periods. Ante-natal care Antenatal care coverage, especially by a trained provider, has increased over time although remains low. One-third of women received an antenatal check-up from a medically trained provider in 1999-2000 compared to one-half (49%) in 2004 (BDHS 2004). Thirty-one percent of women receive ante-natal care from a doctor and 17% receive from a nurse, midwife or paramedic. Ante-natal coverage increases with level of mothers’ education and household economic status, but decreases with birth order. The percentage of women who had three or more ante-natal visits with any provider increased from 16 to 27% between the 1999-2000 and 2004, the medial number of visits being increased from 1.8 to 2.9. The urban-rural difference in antenatal care coverage is also quite large (71% vs. 43% respectively) (BDHS 2004). Delivery care Nationally nine in every ten births in the last five years took place at home while only 9% occurred in a health facility (BDHS 2004). Delivery in health facility is substantially higher among women who have completed secondary education (44%) and among those in the highest wealth quintile (30%). Around 13% of babies are delivered by doctors, trained nurses, or midwives. TBAs continue to play a major role, with 12% mothers reporting assistance from trained TBAs and 63% reporting assistance form untrained TBAs. Nine to eleven percent of deliveries are

9

assisted by relatives or friends (NIPORT, Mitra and Associates, & Macro International Inc. 2003; BDHS 2004). Post-natal care Care after birth is seriously inadequate. Only 18% of mothers receive post-natal care (PNC) from a trained provider within six weeks after delivery. Among mothers who do not deliver at a health facility, only 8% receive PNC. The likelihood of receiving PNC for mothers has improved slightly, from 14% in 1999-2000 to 18% in 2004 (BDHS 2004). Only 15% of mothers with a birth in the past five years reported receiving a vitamin A dose during post-partum period. Family planning services There has been significant improvement over the years in access to family planning services. Overall, 58% of the currently married women in Bangladesh are using a contraceptive method and 11% are relying on traditional methods. Pill is by far the most widely used method (26%), followed by injectables (10%), periodic abstinence (7%), female sterilization (5%) and condoms and withdrawal (4%) (BDHS 2004). Status of child health Infant and child mortality rates reflect a country’s level of socioeconomic development and quality of life. The neonatal and under-5 mortality rates are still higher in Bangladesh. Bangladesh ranks seventh among the 42 countries contributing to the 90% of all childhood deaths worldwide (Black et al. 200). This section addresses the state of child death, their nutritional status, childhood illnesses and service utilization in Bangladesh. Child death A comparison of neonatal, post-neonatal, infant, child and under-5 mortality rates from the demographic and health surveys shows changes over the last decade (Table 2). The comparison shows continued declines in child (1-4 years) and under-5 mortality rates. Between the most recent five-year periods, there was a 20% improvement in child (1-4 years) survival, but there is no evidence of change in infant survival in recent years. No change is observed in neonatal mortality during the last 10 years. Thus, any child health intervention may need to focus on reducing neonatal deaths since most infant deaths occur during the first month of life.

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Table 2. Neonatal, post-neonatal, infant, child and under-5 mortality rates for five-year periods preceding the 2004 BDHS Infant Child Under-5 PostData source Approximate Neo-natal mortality neonatal mortality mortality mortality reference mortality period BDHS BDHS BDHS BDHS

2004 2000 1997 1995

1999-2003 1995-1999 1992-1996 1989-1993

41 42 48 52

24 24 34 35

65 66 82 87

24 30 37 50

88 94 116 133

Source: Bangladesh Demographic and Health Survey 2004

The perinatal mortality rate is 65 per 1,000 pregnancies (BDHS 2004) which is slightly higher than it was in 1999-2000 BDHS (57 per 1,000 pregnancies). Perinatal mortality is higher among teenage mothers and during first pregnancies. There are virtually no urban-rural differences in perinatal mortality and very little difference in infant mortality. Child mortality, however, is positively associated with no/low maternal education, rural residence and short birth interval. Causes of death The two most important causes for under-5 children’s death are serious infections (31%) from ARI and diarrhea (BDHS 2004; Baqui et al. 2001; Fauveau et al. 1994). Comparison of surveys revealed that deaths due to almost all causes, especially infectious diseases, declined (Baqui et al. 2001). The reduction of ARI related deaths was almost entirely limited to children 1-4 years old; there was almost no decline in ARI deaths in the neonatal and post-neonatal period. ARI particularly affect children aged 1-11 months (21%). Birth asphyxia (12%) which occurs in the first 28 days, diarrhoea (7%), pre maturity/low birth weight (7%) and malnutrition were responsible for most of the newborn deaths (BDHS 2004; Baqui et al. 1998; Baqui et al. 2001; Fauveau et al. 1994). Nutritional status More than one-third of the 3.33 million infants born annually weigh less than 2.5 kg, the cut-off point for low birth weight (LBW) (Baqui et al. 1998). About 43% of Bangladeshi children under-five are stunted and 17% are severely stunted. The prevalence of stunting increases with age from 10% of children under 6 months of age to 51% of children aged 4859 months. Additionally, 13% of children are wasted and 1% is severely wasted. Weight-for-age show that 48% of children under-5 are underweight with 13% severely under-weight. Child nutrition levels showed a substantial improvement from 1996-97 to 1999-2000. Since then no noticeable improvement has occurred except that the severe stunting has

11

slightly decreased and overall wasting has increased from 10 to 13% (WHO 2004). Service utilization Immunization The government's policy for childhood immunization which follows the WHO guidelines calls for all children to receive: a BCG vaccination against tuberculosis; three doses of DPT vaccine to prevent diphtheria, pertusis and tetanus; three doses of polio vaccine; and a measles vaccine. A pilot programme on Hepatitis B vaccination has recently commenced. As many as 73% of Bangladeshi children aged 12-23 months can be considered fully immunized (BDHS 2004). Although the level of coverage for BCG and the first two doses of DPT and polio is above or around 90%, the proportions who go on to complete the third dose of these two vaccines fall around 81-82%, while a much lower percent (76%) receive the measles vaccine. Only 3% of children aged 1223 months do not receive any childhood vaccinations (BDHS 2004). This success came from appropriate mass media campaign, service delivery and community mobilization of the EPI programme. Intake of vitamin A Deficiency of vitamin A can be avoided by giving children vitamin A capsule usually every six months. Vitamin A supplementation among children aged 12-59 months increased from 80 to 84% between the 1999-2000 BDHS and the 2004 BDHS but dropped by half for children aged 9-11 months (from 73 to 38%). Childhood illnesses There has been a shift toward greater use of commercially available packets of oral rehydration salt (ORS), from 61% in 1999-2000 to 67% in 2004 (BDHS 2004). Overall 83% of the children with diarrhoea received ORS, recommended home fluid or increased fluids. Of the 21% of under5 children who suffered from acute respiratory infection, only one-fifth were taken to a health facility or provider for treatment. The proportion seeking care from a trained provider for children with ARI declined over the period i.e. 20% in 2004 compared to 27% in 1999-2000 (BDHS 2004). Among 40% under-5 children having fever, nearly two-thirds were taken to a provider for treatment, but only 19% were taken to a medically trained provider/facility (BDHS 2004).

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Healthcare delivery system for maternal and child health Maternal and child health care in Bangladesh is provided by government and non-governmental agencies. The Ministry of Health and Family Welfare (MOHFW) is responsible for health policy formulation, planning and decision-making at the macro level. Under MOHFW, there are two implementation wings: the Directorate General of Health Services (DGHS) and Directorate General of Family Planning (DGFP). The DGHS is responsible for implementation of all health programmes and technical support to the ministry. The DGFP is responsible for implementing family planning (FP) programmes and providing FP-related technical assistance to the ministry. DGHS and DGFP work independently. The DGHS advises and supports medical college hospitals, district hospitals and upazila health complexes (UHC), while DGFP oversees operations of district-level maternal and child welfare centres (MCWC) and union-level Union Health and Family Welfare Centres (UHFWC). At the most peripheral level both wings work at the domiciliary level to bring essential services to the people’s door step. Level of care and type of health facilities Most of the country’s health infrastructure and health service system are under the government’s management and control. The health service delivery system in the public sector is divided into primary, secondary and tertiary levels. Table 3 provides a summary of health facilities available at different levels. At the local level, 3,275 UHFWCs exist to serve 4,470 unions. There are UHC with 31 beds in 391 rural upazilas, 64 district hospitals, and 16 government medical college hospitals, 6 post-graduate hospitals, and 25 specialized hospitals at tertiary level in the country. A further 89 MCWCs have been upgraded to provide EOC services, and other services (ANC, normal delivery, PNC and clinical contraception) at district, upazila and union level, one for every one to two million population. Nine more MCWCs are under construction at the district level. In addition, the government recently undertook an initiative to establish community clinics, one for every 6,000 peoples at the village level. Fifty-four MCWCs at the district level and six at the upazila level are equipped to provide 24-hour comprehensive EOC; the rest provide 24hour basic EOC. In addition to the basic reproductive health and family planning (RH-FP) services, UHFWCs at present are offering surgical contraceptives, norplant, safe delivery, obstetric first aid1, newborn care, and adolescent healthcare.

1

The services under obstetric first aid include administering parenteral oxytocic drugs, antibiotics, sedatives, anticonvulsants and referral.

13

Table 3. Type of health facilities according to the level of care Level of care Primary level

Administrative unit Health facility Village Satellite clinic (8 per month per union) Community clinic (11,500) Skilled birth attendants NGO workers Community groups Union Union Health & Family Welfare Centre (3275) MCWC (23) Hired clinic (300) Upazila Upazila Health Complex (397): 31 beds each MCWC (12): 13 Beds each Secondary level District District hospital (59): 50-150 beds each MCWC (54): 13 beds each MCWC (9): under construction MCH unit (3) Tertiary level Division or national Teaching hospital/institute (16): 250or capital 1050 beds each Maternal & Child Health Training Institute (3) Mohammadpur Fertility Services and Training Centre (1) Source: Programme implementation plan (PIP), HNPSP, 2003; Pp 133-157.

The district hospitals in the district headquarters provide maternal services through an outpatient consultation centre and labour ward. Between 25-40% of hospital beds are reserved for maternity patients in every hospital. Many of the district hospitals are not providing 24-hour essential EOC services due to lack of trained staff and related support facilities. Similarly more than 80% of the UHCs are not ready to provide 24-hour EOC services. The Maternal and Child Health Training Institutes (MCHTI), Azimpur, Dhaka is a 173 beded hospital cum training centre. MCHTI provides safe motherhood services including comprehensive EOC, gynecological services including hysterectomy, newborn care, child health care and FP services. They also provide training on EOC, SBA, midwifery and newborn care. There are two more MCHTIs in Rajshai and Barisal. EOC services would also be started and expanded in phases in Mohammadpur Fertility Services and Training Centre, Dhaka. Besides the public sector, the private for-profit providers and private notfor-profit providers or NGOs also play great role in the Bangladesh health sector. NGOs are mostly involved in the provision of primary healthcare in both rural and urban areas. A significant number of tertiary hospitals are run on a not-for profit basis. NGOs run a total of 613 health facilities, which have 11,271 beds (DGHS 2000). 14

The child health and nutrition component of the essential services package (ESP) including control of vaccine preventable diseases through the EPI programme, management and control of acute respiratory infection (ARI) and childhood diarrhoeal diseases, and supplementation of vitamin A capsules are being provided at all levels. GO-NGO collaboration NGOs are playing complementary and supplementary role to the overall performance of the national MCH-FP programme. During 2002-2003, three NGOs namely 1) BWHC in collaboration with RH-STEP and BPASA, 2) BAVS, and 3) BRAC were selected through bidding following International Development Agency (IDA) guidelines for providing selected health services. The areas of NGOs collaboration were – (1) permanent and longer acting family planning method, (2) safe MR services and training, and (3) increasing coverage of family planning, safe motherhood and adolescent healthcare in low performing areas. Since continuation of services by these NGOs is necessary, the process of negotiation with bilateral donors is in progress for funding. During HNPSP, as per decision of the government, BAVS continues to provide family planning clinical services. There are about 400 NGOs working at national and local level across the country in the field of MCH-FP through domiciliary and clinic-based services, and community mobilization. During HNPSP, it is intended to record and map NGO service areas and the scope of MCH-FP services provided by NGOs in the geo-referenced databases of the Family Planning and Health Services Directorates in order to avoid overlapping with the GoB services. Linkages and collaboration with other development ministries and agencies Within the health sector, linkages have been established with different programme directors for proper and effective implementation of MCH-FP services at different level. Collaboration has been made with DG, NIPORT for capacity building of personnel working for delivering and management of MCH-FP services, demographic and health survey, and research. Similar linkages were made with NNP and DGHS for nutritional promotion of pregnant and lactating mothers, children and adolescents, and for case management of violence against women respectively. In order to implement interventions effectively at the local level, coordination has been made with NGOs, private sector and local government bodies. To ensure smooth implementation at central and peripheral level, collaboration with development ministries including Education, Information, Women and Children Affairs, Agriculture, Fisheries and Livestock, Forest and Environment, Local Government, and Home and Defense has been established.

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POLICY-MAKING IN THE HEALTH AND POPULATION SECTORS In order to address the poor state of MNCH, the government of Bangladesh has undertaken several initiatives since independence. In 1985, safe delivery became a key component in the GoB's MCH strategy. The first assessment of maternal health services was done in 1988. The recommendations based on it were translated into the planning process for the Fourth Population and Health Programme, which continued up to 1998. In order to detect early and refer complicated cases, the EOC programme was undertaken in early 1990s and the rights-based comprehensive National Maternal Health Strategy was adopted in 2001. The strategy has been integrated into the Health and Population Sector Programme, (HPSP 1998-2003) and into its follow-up the Health, Nutrition and Population Sector Programme, (HNPSP 2003-2006). NGOs and bilateral agencies have played a vital role behind the success of the population sector as they provided specific policy recommendations based on research-based intervention programmes. This section of the report reflects the key questions surrounding enabling policy environment, and responses in the MCH arena in Bangladesh in terms of sufficiency, achievements, gaps and challenges and future directions. To facilitate the review, following areas have been identified: x Improving maternal and child health through health policy x Major interventions on MNCH, and achievement of beneficial impacts x Gaps between policy and implementation x Lessons learned. Improving MNCH through health policy Historically, health and population sectors in Bangladesh have been viewed as distinct policy areas for public action and investment. The Health and Population Sector Strategy (HPSS) was formulated within this background in consultation with donors, UN agencies (UNDP, WHO, UNICEF and UNFPA) and important stakeholders (GoB/HPSS 1997). The HPSS has a long-term vision of a sector that is responsive to the needs of clients, especially women, provides quality services, has adequate delivery capacity and is financially sustainable specially addressing the needs of the poor. It aimed at provision of one-stop full-range essential reproductive health and family planning services through an integrated service delivery mechanism. The shift to the sector-wide management was assumed to promote more efficient service delivery and better

16

coordination among donors, besides cutting down wastages. Subsequently, the Health and Population Sector Programme (HPSP) was formulated which is expected to reduce maternal mortality and morbidity. Project Implementation Plan (PIP) of HPSP was also put in place since July 1998. The major component-wise outcome of the programme included 1) a well defined Essential Service Package (ESP)2, 2) unified, restructured and decentralized service delivery mechanism, 3) integrated support system, 4) focused hospital level services, 5) strengthened policy and regulatory framework, and 6) strengthened public health services. Some major milestone activities were also proposed in the HPSP such as establishment of community clinics, provision of comprehensive EOC in UHCs and basic EOC in all UHFWCs, ensuring more funds for medicines and other surgical requisites, improving management of hospitals, and improving accounting and financing of the sector (HNPSP 2004). But the imperative to provide good quality curative healthcare such as EOC would require expensive technology and costly human and physical infrastructure. The issue of financial sustainability in the context of reforms initiated under the HPSP was of particular concern in view of the rising programme costs and a likely reduction in donor financing. On the programmatic side, the pooling of donor funds into a common pool had, quite predictably, created considerable additional barriers to implementation by delaying aid disbursement. Although the stated goals of the HPSP reflect the government’s development goals of poverty alleviation and human development, its performance has been undermined by the inability to reorganize service delivery, a consequence no doubt of the broader governance challenge facing Bangladesh. Initially public health services were not targeted specifically to the poor. However, the fact that services were provided free indicated an implicit concern that the poor should not be excluded. The Fifth Five-Year Plan (FFYP) (1997-2002) of the GoB was formulated in 1998, and aimed at creating a greater degree of public awareness of the population issue through a social movement to reach replacement level of fertility by the year 2005. The focus of FFYP was on a reproductive health sub-programme aimed at extending the coverage of reproductive health services, including efforts to improve safe motherhood, quality obstetric care, clinical methods of contraception, and the management of reproductive tract infections (RTI) and sexually transmitted infections (STI). Issues of gender equity and equality and reproductive rights were introduced in the programmes of education, law enforcement, religious affairs, the garments, tea plantation industries, 2

The elements of ESP are grouped into following five areas: reproductive health care, child health care, communicable disease control, limited curative care and behavior change communication.

17

and other sectors. The FFYP also completed a phased programme to upgrade a network of 64 MCWCs to ensure that they have the needed equipment and training staff in EOC so that these can offer a package of comprehensive maternal health services. The HPSP came to an end on June 2003. The GoB revised the HPSP and formulated the new Health, Nutrition and Population Sector Programme (HNPSP) 2003-2006. The vision and target outlined in the i-PRSP have been taken as an overarching long-term policy framework and a signal of the political commitment of the government upon which the HNPSP is developed and contributes to poverty reduction in the country. The goal of the HNPSP is sustainable improvement of health, nutrition and family welfare status of the country's population, especially the vulnerable, e.g., the poor, the women, the children and the elderly. The purpose will be to increase the availability and utilization of user-centered, effective, efficient, equitable, affordable and accessible quality services for a defined ESP plus other selected services. The HNPSP is committed to reduce fertility, maternal and under-5 mortality under the broader context of reproductive health. The priority objectives and achievements so far of this effort are described in Table 4. By re-invigorating programme efforts directed at improved maternal health, reduced child mortality and malnutrition, reduced fertility and disease control, HNPSP is expected to contribute significantly to the achievement of MCH-related MDGs. Table 4. Target and progress of HNPSP to meet MDGs MDGs HNPSP (1990- priority 2015) objectives

Reduce ¾ of MMR

Reduce 2/3 of under5 mortality

3 4 5 6

Unit of measurement

Bench -mark

Projected Required Projected HNPSP target annual rate of performance rate of progress targets on Mid- Midtrack for during 2003 2006 progress MDG HNPSP Yes Annual Reduce Met need for 12.6% 13.0% 25% Annual 3 reduction reduction MMR EOC of MMR Maternal death/ 3.24 2.95 2.75 of MMR by 7.5 per by 6.7 per 1000 live births Reduce Lifetime # of 3.2 2.8 100,000 100,000 3.35 TFR birth per woman Reduce % of under 50.9 48% 42% Annual Yes Annual malnuweight children %6 reduction reduction trition (6-59m) of under- of under5 Reduce Infant death/ 66.35 56 48 5 mortality mortality infant 1000 live birth rate by and Under-5 94.05 80 70 rate by 3.6 per 3.3 per under-5 deaths/1000 1000 1000 mortality live births

UMIS estimate based on EOC report from 218 GOB facilities BMMS, 2001 BDHS, 1999-2000 Bangladesh child nutrition survey, 2001

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Major interventions on MNCH in Bangladesh Rates of morbidity and mortality among pregnant women, mothers and newborns remain high in Bangladesh, particularly among poorer groups. Access to skilled and timely care is the key to reduce the toll of maternal and neonatal deaths. The MDGs on maternal health and child mortality helps circumscribe the MNCH in Bangladesh. Under HNPSP, the government has undertaken five sub-programmes including a) family planning services, b) clinical family planning services, c) MCH care and services, d) adolescent healthcare, and e) support services and coordination, which are being implemented through countrywide facility network as describe in Table 3. Several bilateral agencies (UNICEF, UNFPA, WHO, EU, etc.) and NGOs (BRAC, CARE Bangladesh, BPHC, Engender Health, ICDDR,B, NSDP, PSTC, etc.) are providing hospital or community-based services or both in order to supplement and complement government’s initiatives in this field. International and national human rights and health advocacy are also playing a major role in this regard. Some major MNCH interventions are as follows: A) Maternal health intervention x Reproductive health: MCH-FP services x Emergency obstetric care x Menstrual regulation programme x Skilled birth attendant programme x Community midwifery programme x Urban primary health care project x NGO service delivery programme B) Child health intervention C) Saving newborn lives programme D) Kangaroo mother care project E) National communication campaign programme F) National nutrition programme for mother and child

19

MNCH INTERVENTIONS IN THE RURAL AREAS

Introduction Despite unfavourable socioeconomic situation such as low literacy rate, poverty, low status of women, religious barrier, gender disparity, the MCH-FP programme has made remarkable successes over time. Table 5 shows the achievement of the MCH-FP programme during the last three decades. Table 5. Success in the field of MCH-FP over time Indicators Contraceptive Prevalence Rate (CPR) Total Fertility Rate (15-49 yr. aged woman)

71-75 7.7

82

6.3

85-88 25.3

Year 93-97 39.9

96-97 49.2

99-00 53.8

2004 58.1

4.8

3.4

3.3

3.1

3.0

Infant Mortality Rate (per 1000 live births)

-

-

-

-

87.4

82.2

66.3

65

Under-5 Mortality Rate (per 1000 live births)

-

-

-

-

113.1

115.7

94

88

Maternal Mortality Rate (per 100,000 live births)

-

620

-

-

-

-

320 (2001)

-

Unmet need for contraception

-

-

-

-

19.4

15.8

15.3

11.3

(Source: BDHS 2004 & BMMS 2003)

The contraceptive prevalence rate (CPR) has increased from 7.7% in 1975 to 58.1% in 2004 and total fertility rate (TFR) declined from 6.3 in 1971 to 3.0 in 2004 (BDHS 2004). The population growth rate decreased from 3% in 1971 to 1.47% in 2001 (BBS 2001). Life expectancy at birth has increased to 64.5 years for males and 65.4 years for females in 2003 (BBS 2004). The infant and under-5 child mortality rates have declined from 87 per 1,000 live births and 133 per 1,000 live births in 1993 to 65 and 88 in 2003 respectively (BDHS 2004). The MMR has also fallen from 620 per 100,000 live births in 1982 to 320 in 2001 (NIPORT, ORC Macro, John Hopkins University, ICDDR,B, 2003). Considering progressive 20

improvements, maternal and child health status is seemingly reaching close to the stated outcome set for the MDGs. In this chapter, we explore in detail the different MCH-FP interventions that have been running during these times, both in the public as well as in the private sectors including the not-for-profit NGO sector. Reproductive health (RH): MCH-FP services of the government of Bangladesh Under the Directorate of Family Planning, MCH-FP services are provided within the broad framework of reproductive health through strengthening field and institutional service delivery system capabilities to facilitate decline in fertility, maternal, infant and child mortality and morbidity. The RH:MCH-FP unit has provided relevant services through Maternity and Child Health Training Institute (MCHTI), Azimpur, Mohammadpur Fertility Services and Training Center (MFSTC), 95 MCWCs including 67 EOCs, 402 UHCs’ MCH-FP units, and about 3,500 UHFWCs. Interventions The RH:MCH-FP services are the components of ESP under the HNPSP. The prioritized services are: 1.

2.

3.

4.

Safe motherhood services comprising ANC, safe delivery by SBA, EOC, safe MR services and post-abortion care, PNC with vitamin A supplementation, maternal nutrition through iron and folic acid and vitamin A supplementation, syndromic management of RTI/STI, counseling on HIV/AIDS and condom promotion, prevention of unwanted pregnancy through introduction of emergency contraception, screening for cervical cancer, services for violence against women and gender equity, and essential newborn care; Family planning services including injectable, IUD, norplant, vasectomy, tubectomy, condom, oral pill, recanalisation, and infertility; Adolescent healthcare for girls and boys comprising development of adolescent health strategy; counseling and developing awareness on sexual and reproductive health issues including awareness on HIV/AIDS, management of minor gynaecological problem (dysmenorhea and menorrheagia); syndromic management of RTI/STI; condom promotion for married adolescents; and full immunization of adolescent girls with five doses of TT vaccine; Child health care services including IMCI, routine and expanding immunization, vitamin A supplementation, management of drowning, injury and accident, and limited care for eye, ear and skin infection.

Source: HNPSP, PIP 2004

21

Service delivery mechanism Both domiciliary and facility-based approaches are followed for delivering MCH services in rural areas. At the community level the door-step MCH services are provided by the family welfare assistants (FWA) and health assistants (HA). Each FWA visits 20-25 households in each working day and covers her catchment area 2-3 months for follow-up, supply of oral contraceptive pills, condoms, vitamin A capsules, ORS, and health education on ANC, PNC, newborn care, EPI, longer acting FP methods, nutrition, hygiene practices, adolescent health, etc. Besides, 30,000 satellite clinics (SC) (8 SC per union) are arranged every month by the local health-FP workers for providing ANC, PNC, FP including follow-up and side-effect management, EPI, child healthcare, and adolescent healthcare to the poor at the grassroots (WHO 2004, HNPSP 2003). At the union level a family welfare visitor (FWV) and a Sub-Assistant Community Medical Officer (SACMO) or medical assistant are providing services through UHFWC. In addition, about 250 graduate medical officers are posted in 3,275 UHFWCs for managing complicated and referred cases. The government is committed at least one skilled birth attendants (SBA) at every UHFCW (4,500 SBAs) to complement the facility approach to obstetric care. The SBAs are to provide normal safe delivery in homes and referral to the EOC sites if needed. As of 2004, 390 SBAs were trained and 4100 still need to be trained (HNPSP 2004). The existing FWAs and female HAs in the government sector were trained as SBAs. In order to ensure SBA at deliveries and managing obstetric complications, FWVs (SSC qualified) go through a 18-month midwifery training (WHO 2004) and are posted at the UHFWCs in midwifery as well as in supervision. The last training was in 1999 and in 2006 government decided 6 months refreshers training to FWVs to ensure safe normal delivery. At the upazilla level, the MCH unit of UHC, headed by a graduate medical officer (MO-MCH) provides MCH services. The gynaecological junior consultant, MBBS plus at least one year training on gynaecology, attends all births at the UHC, emergencies, complicated and referred maternal cases. FWAs are responsible for family planning services. Nursing and midwifery care is provided by the senior staff nurses who have one-year midwifery training. These activities at MCH unit of UHC are supervised by the UHFPO. At the district level, in the MCWCs, a medical graduate (MO-clinic) having training on gynaecology provides maternal and neonatal care, and the medical officer (MCH-FP) provides support as anesthetist. The gynaecology consultant of the MCH unit at district hospital (DH) renders services for normal, complicated and referred maternity cases. In DH, there are nine other specialized units (pediatrics, anesthesia, medicine, surgery and others) also serving if necessary. 22

Human resource development Table 6 provides an outline of the essential training requirements by the year 2010 that is necessary to ensure that maternal health care is able to be provided for on daily basis at the current staffing levels for the various levels of the health system. A detail annual training plan has prepared based on the required skill mix, existing skills of service providers, capacity of available training facilities, and priority of training activities. This plan prioritizes the EOC training needs and will also highlight the long term plan for ensuring availability of skilled birth attendance within and closet to the community. In addition, it is necessary to develop a comprehensive master plan which will take account of the staffing and training requirements necessary for ensuring in the long-term full coverage of mental health care, particularly in those centers that are or will be required to provide 24 hour coverage. This would also take into account additional staffing that would be required as performance increases. Table 6. Human resource development plan by 2010 Type of training

Management and Development

Target approximate number

Output

Duration of training

District level manager

200

90% received training

8 days

Upazila level manager

900

Do

6 days

900

Do

6 days

150

Do

6 days

450

Do

6 days

5000

90% received training

6 days

Activities

TOT for comprehensive orientation programme Logistic management (upazila level manager) Store management for pharmacists Monitoring and supervision for union level supervisor (SI, FPI, Sr. FWV) FWV basic training

FWV refresher training on midwifery skill Clinical training (Basic practice and refresher) SBA training 1 week refresher training of FWV (modular training)

1585+550

90% received 18 months training

1320

Do

6 months

2400

Do

6 months

3900

Do

6 days Continued…

23

Table 6 Continued

Type of training

Activities

Comprehensive norplant and VSC training for doctors Refresher training on NSV for doctors EOC training for anesthetist, obstetrician, FWV Training on clinical contraception for FWV and SACMO of 1500 upgraded UHFWCs Refresher training on IUD for FWV Basic training on MR for doctor Basic training on MR for paramedics (FWVs and female SACMO) Refresher training on MR for doctor Refresher training on MR for paramedics Training on essential newborn care for doctors of MCWC Training on essential newborn care for paramedics Basic training Basic training of FWAs Team training Team training of FWA

Orientation

Team training of FPI Team training of SI, AFPO, Sr. FWV Orientation on planning process for newly recruited doctors and UFPOs Orientation for field functionaries (union/ward/village) on health nutrition and population

Source: HNPSP 2003

24

Target approximate number

Output

Duration of training

400

90% received training

4 weeks

300

Do

2 weeks

200

90% received training

6 months

1500

D0

2 weeks

2500

Do

6 days

450

Do

12 days

750

Do

14 days

520

Do

4 days

750

Do

6 days

250

Do

6 days

1100

Do

6 days

6100 6000

90% received training 90% received training

1 month 6 days

3500

Do

500

Do

600

Do

6 days

6000

90% received training

2 days

Role of NGOs in MCH-FP programme In Bangladesh, NGOs have played a significant role in the development of the MCH-FP programme across the country. At present, over 400 NGOs operate in various areas of the country covering different aspects of MCH-FP related activities. The NGOs operate with government approval and as per the government's guidelines to complement and supplement the national programme. Most are involved in community-based distribution of contraceptives, clinical family planning services integrated with income generating activities, MCH and nutritional activities, research and evaluation, and social marketing of contraceptives. In the following sections, major successful NGO projects in Bangladesh are described. MCH-FP project of ICDDR,B at Matlab In 1977, ICDDR,B started an experimental MCH-FP programme at Matlab, a riverine rural sub-district (upazila) of Bangladesh. Special services were introduced in 70 villages with a population of 89,350 (study area) and demographic dynamics were monitored in a neighbouring 79 villages (comparison area) with a population of 85,596. In the comparison area where usual government services were provided, socioeconomic and demographic conditions were otherwise comparable to those in the treatment area. In the treatment area, female community health workers (CHW) visited all currently married women twice a month, consulted about their contraceptive needs and provided contraceptive care. Basic health problems were addressed by MCH outreach, and referral services were available at nearby clinics. In the initial project period, health interventions were family planning support oriented. However, with time the service regimen has expanded to incorporate immunization, oral rehydration therapy, training of TBAs, provision of safe delivery kits, and nutrition education, etc. (Bhatia et al. 1980 and Rahman 1986). Moreover, ICDDR,B developed a scheme for the placement of trained midwives in the villages to provide services for pregnancy, delivery and referrals as required. The midwives were linked to CHWs, who referred pregnancy and delivery cases to these midwives (Maine et al, 1996). A midwife is a CHW/FWV with 8-10 years of schooling or having secondary school certificate received 18 months midwifery training. In 1996, the programme was resigned for facility-based birthing by midwives (Marge et al. 2006, Elahi et al. 2006). Between 1996 to 2001, all four health centres were upgraded and equipped to perform basic obstetric care, home births with midwives were no longer offered. The government-trained nurses or midwives provided ante-natal, homedelivery, and post-natal care; identified and treated complications; organized referrals and accompanied patients to the central clinic at Matlab. The midwives are supported by two other components of the

25

programme namely, development of a referral chain, including a boatman and helper to accompany patients at night or day to the central clinic, and installation of a maternity clinic at Matlab where trained paramedics and female physicians are always available for obstetric first aid and treating obstetric complications, or further referral to a district hospital. Patients requiring cesarean section and blood transfusion are referred by ambulance to the district hospital (Fauveau et al. 1991). Achievements so far By 1978, evidence of demographic impact was apparent, and by 1981, the effects were substantial. By 1982, CPR had risen in the Matlab treatment area compared to the comparison area, and above the national averages (Menken and Phillips 1990). In 1990, three of every five eligible women residing in the project area were contraceptive acceptors and the TFR was below four. The Health and Demographic Surveillance Report (2004) shows that TFR in ICDDR,B area was 2.9 and in government services area was 3.1. After 2000, the fertility rate of the two area converged and in 2005 the TFR in the government area was 2.8 (HDS 2007). The IMR in ICDDR,B and government-served areas were respectively 39.1 and 48.5 per 1,000 live births. The NMR fell in ICDDR,B area and while it rose in government service area The post-neonatal and under-5 mortality rates fell in both areas, however, the declining trend was significantly higher in ICDDR,B area (HDS 2004). The use of facilities for delivery was over twice (about 21%) the national level at Matlab in 2001. Between 1987 and 2005, the percent of births with a skilled attendant increased from 5.0% to 53% (HDS 2007) and from 1996 all births with a midwife were health centre based. The caesarean rate has increased steadily from 0.2% in 1990 to 6.8% in 2005 (HDS 2007). Maternal mortality remained stable between 1976 and 1989 but decreased substantially after 1989. From 1990 onwards maternal mortality declined by 7% per year in the ICDDR,B service area compared to 4% per year in the Government service area. During 2001-2005, MMR in ICDDR,B area was 120/100,000 pregnancies and 200/100,000 in government area which were lower than the national average (Chowdhury et al. 2006). The speed of decline was faster after the introduction of the skilled attendance strategy, better access to emergency care, and fall abortion mortality in ICDDR,B service area. The observed changes in the treatment area strongly suggest that the project was successful in adapting the service delivery strategy to the social conditions in rural Bangladesh (Simons et al. 1987). MCH-FP extension project: collaboration between ICDDR,B and the GoB The sharp increase in the CPR and its consequent impact on fertility in the Matlab project area raised question of its replicability in other areas

26

of Bangladesh. In order to test the feasibility of incorporating the lessons learned from Matlab, in 1982 ICDDR,B, in collaboration with the government, started a project, called MCH-FP Extension Project in two other upzilas of Bangladesh i.e, Abhaynagar in Jessore district and Sadar upazila in Sirajganj district. The strategy was to transfer apparently successful elements of the Matlab programme into the government services, without requiring much more than the resources available and without changing the overall rules governing lines of authority, recruitment, transfer, promotion, and pay (Phillips et al. 1984). This new project was to be collaborative, with research direction provided by ICDDR,B and operational direction by the usual government administrative system. In the extension project, the ICDDR,B interventions were designed to strengthen the knowledge and supervisory capabilities of mid-level government officials to implement programme activities at the field level. The primary objective was to train the government field workers about the client-oriented motivational approach. Several four-week on-the-job training programmes were conducted at field level to discuss family planning, oral rehydration, tetanus immunization, household visiting patterns, motivational techniques, community relations, referrals and record-keeping. Salient features of the extension project design that have been kept over the years include 1) field offices used as ‘policy laboratories’; 2) collaboration with government officers at both central and field levels; 3) demographic surveillance and periodic surveys at project sites, and increasingly qualitative research; and 4) a focus on implementation issues (Phillips 1987). In the ICDDR,B Extension Project areas the contraceptive use rate is substantially higher than the national rate. The findings indicate that the programme performance in the government can be improved by introducing simple interventions. Household visiting patterns, motivational techniques, community relations, referral and recordkeeping are found critical to the success or failure in large scale government programmes (Phillips 1987). BAMANEH’s MCH project: community-based mother and child health care services To curb the increased rate of maternal and infant mortality, especially in rural areas, Bangladesh Association for Maternal and Neonatal Health (BAMANEH), a national NGO as well as an affiliated body of the International Associational for Maternal and Neonatal Health (IAMANEH) was established in 1979. Since its inception, BAMANEH has been contributing significantly in family planning, TBA training, reproductive and child healthcare, and action research on health-related issues.

27

The intervention In the early stage, it was recognized that the very objective of maternal and child mortality reduction could be achieved to a great extent by TBA training if safe deliveries are assured. Later the services of the villagebased TBAs were extended to include family planning motivation and healthcare awareness with financial support from Asia Foundation. The project encouraged mobilization and active participation of community people to develop a sustainable MCH programme. BAMANEH undertook ‘community-based MCH care project’ in Chandina upazila of Comilla district with support from Swiss Red Cross (SRC) in 1986 and in Gabtoli of Bogra district in 1988. The project was expanded in Sadar upazila of Bhramanbaria district and in Alfadanga upazila of Faridpur district during 1992-1993. Thereafter, similar project was initiated in Sariakandi upazila of Bogra district in 1998 with support from IAMANEH. The MCH care focused on ANC, safe delivery, PNC, basic curative treatment, BCC activities, EPI for women and children, growth monitoring, and mobilization of community people through mothers’ club and health committees. The project covers 104,662 people in 61 villages of five districts. Achievements so far In co-operation with government’s EPI programme, BAMANEH has succeeded in bringing a positive change in immunization coverage. BAMANEH conducted a study in 1993 on ‘standardization of FP, MCH and midwifery kits’ which revealed that the project has created a sense of inspiration and enthusiasm among its beneficiaries to improve their health. TBAs, especially in Chandina, Bhrammanbaria and Alfadanga, are motivated to work voluntarily that has a positive impact on reducing MMR which is lower than (220/100,000 live births) the national average (BAMANEH 2004). Nearly two-third of the deliveries in the project catchment area are conducted by trained TBAs. Empowerment of TBAs in the project areas with continued training has enhanced their credibility. Strong and effective healthcare motivation has raised the life expectancy, standard of living, and child survival rate. Growth monitoring programme has brought a positive impact on the nutritional status of under-5 children. About 16% of the children within the age group of 0-3 years are in the growth monitoring programme. Formation of para/village-wise health committee has opened up a new vista to organize and mobilize community people in smaller fora to identify their felt-needs on different health issues, and how to utilize their participatory efforts to ameliorate those problems. Child delivery at BAMANEH clinic rather than home is the persistent demand of the community which also increased revenue generation.

28

Birth and re-birth of knowledge from BRAC BRAC’s engagement in health started in 1972 (Rohde 2005); which summarized in Table 7. From the very start, BRAC has been moving forward along the direction of global and national health strategies to address the local health situations (Chowdhury and Cash, 1996). BRAC gained immense knowledge, particularly in improving child health throughout the 1980s. In early nineties BRAC trained 13 million women in Bangladesh how to prepare and use oral rehydration solution for treating diarrhoeal diseases at home and created concurrently a miracle in childhood immunization (Chowdhury and Cash 1996; Chowdury et al. 1999). At this juncture, BRAC conceived the idea of life cycle approach for improving maternal and child health. This idea gave rise to the origin of Women’s Health and Development Programme (WHDP) addressing women’s health through comprehensive approach (BRAC Women’s Health and Development Programme, 1992). At the same time, BRAC also crafted the Essential Health Care (EHC), a low-cost basic health intervention, particularly for the poorer sections of the community which included health and nutrition education, water and sanitation, family planning, immunization, pregnancy related care, basic curative services, tuberculosis, essential healthcare for specially targeted ultra poor, and training (Annual Report of BRAC Health Programme 2003). In 1996 the focus of women’s health turned to reproductive health echoing with International Conference on Population and Development (ICPD) in Cairo in 1994 and the Fourth Women’s Conference in Beijing in 1995 (International Conference on Population and Development 1994; Beijing Declaration and Platform for Action 1995). The resulting Reproductive Health and Disease Control (RHDC) programme moved beyond diseases of the reproductive tract bringing into light the significance of reproductive and sexual health and rights including gender issues. RHDC provided a package of essential reproductive health services viz. adolescent family life education, contraception, maternity care, referral, HIV/AIDS awareness, treatment and prevention of RTI, STI, tuberculosis, ARI and basic curative services. RHDC provides secondary referral facilities through BRAC health Centre or Shushasthya. On the other hand, the Family Planning Facilitation Programme (FP-FP) and the Rural Service Delivery Programme (RSDP) went side by side with other health interventions starting from 1996 to 2001 (BRAC Report 2000). The RSDP establishes informal schools that provide 3 years of primary schooling to adolescents who have never attended school. Monthly reproductive health sessions are integrated into the regular school curriculum include adolescence, reproduction, menstruation, marriage, pregnancy, STIs, family planning, smoking, substance abuse, and gender issues.

29

Malnutrition being acknowledged as a major impediment to health and development, nutrition interventions endorsed by the World Bank and the national government began in 1996 targeting women and children to bring about changes in nutrition behaviour. At the wake of 2005, recognizing the enormity of the problems of maternal and child health, BRAC realized to initiate intensive health interventions to reduce deaths and diseases of women and children under the MNCH programme both in the rural and the urban slum areas. Table 7. BRAC major health programmes and activities Major programme Oral Therapy Extension project (OTEP)

Activities Phase 1 (1980) – to scale, revise 7 points, name for diarrhea External evaluation Phase 2 (1983) - training health services in use of ORT, concentrated reinforcement programme increases use further Rice ORT trials (1985) Phase 3 OTEP started (1986) Conclude in 1990 reaching 13m household

Timeline 1980-1990

Child survival programme (CSP)

Extend intervention for children to Vit A, EPI, nutrition, sanitation, ORT, comprehensive-PHC, facilitation of government programme

1986-1990

Health & population programme

Successor to OTEP/CSP – more comprehensive EHC and WHDP

1990

Women’s Health and Development Programme (WHDP)

Child health and development programme including birthing centre, ANC and nutrition, CSP, NFPE for adolescents-nutrition and health in kishore-Kishori school curriculum, EPI, health resource centre- village organizations, health committees, Gram Committees, drug cooperatives WHDP becomes RHDC – add STI, HIV, TB, ARI to already safe motherhood, ANCC, CSP, etc.

1991-1995

Reproductive Health and Disease Control (RHDC)

1996

Family Planning Facilitation Programme (FP-FP)

Health and family planning facilitation programme in support of government FP

1994

Nutrition facilitation programme

Facilitate Government’s Bangladesh integrated nutrition project

1996

Rural Service Delivery Programme (RSDP)

National facilitation-USAID support- train NGOs, implement essential service package in 8 districts, initiate adolescent family life programme for youth education services

1997

Health, nutrition and population programme BRAC health programme (BHP)

Essential health care (EHC) services

1999

Nation wide essential health care services to the poor

Source: Rohde 2005. NB. The shaded rows are umbrella programmes

30

2002-to date

Achievements so far Identification of pregnancy was the major entry point to reach within the boundary of pregnant women. In WHDP, one-third of the pregnant women were registered during the first and the remaining during the second trimester. Hence, more than 90% of the women received 2-6 antenatal visits and nearly all were immunized with tetanus toxoid vaccine (Afsana et al. 1995). In WHDP, more than 90% of births took place at home assisted mostly by BRAC TBAs. BRAC offered post-natal visits twice at home to more than two-thirds of women during postpartum period. Immunization coverage was substantially high with more than 85% among children in WHDP intervention areas (Afsana and Mahmud 1998). Similar trend was observed for Vitamin A coverage (87%) among under-5 children (Rohde 2005). In WHDP, the ARI control programme was found quite successful especially in offering treatment to under-5 children by the community health volunteers known as Shashthya Shebikas (Hadi 2003). In RHDC programme, the set up of BRAC health centre namely Shushasthya brought into light the accessibility of the disadvantaged population, particularly, members of the BRAC village organization (VO) to facility level care. About three-fourths of the patients attending the Shushasthyas in mid-nineties were BRAC poor members (Afsana and Mahmud 1998). The quality of care maintained in different facilities varied (Afsana and Sabina 2001). Use of BRAC Shushasthya for child delivery was influenced by many factors, such as, socio-cultural barriers, costs, fear of hospitals and so on (Afsana and Rashid, 2001). However, it was reported that the women who gave birth in a Shushasthya spoke of good quality services including maintenance of privacy, dignity, caring attitudes, and emotional support. In FP-FP and RSDP, the partnership experience with the government became more congenial to establish a better working relationship. The contraceptive use was much higher with decreasing discontinuity rate (Hadi 1998). Involvement of male in this programme was quite significant. Besides, adolescents were targeted for better education in sexual and reproductive health (Rashid 2000). In both the Bangladesh Integrated Nutrition Programme (BINP) and the National Nutrition Programme (NNP), nutritional status was reported to be improved among pregnant women and under-2 children (Baseline survey NNP 2003, Endline Survey 2005). However, similar improvement was also observed in control areas. More importantly, low birth weight remained unchanged over the years of nutrition interventions. In EHC, even with small numbers of staff and CHWs, ante-natal coverage was about 62% and contraceptive use was also 59% (Annual Report

31

BRAC Health Programme 2006), which were higher than the national average. About 80% of the children were fully immunized against six communicable diseases and 87% pregnant women were immunised with TT vaccine. The monitoring report suggests that 93% of the under-5 children received vitamin A capsules in BRAC working areas. In addition, in ultra poor families of EHC areas, service utilization was extremely high. Emergency obstetric care (EOC) in rural Bangladesh Intensified efforts on TBA training Comprehensive EOC Functions and utilization of ANC could not reduce maternal mortality at the a. Administration of parenteral desired level. In recent times, antibiotics b.Administration of parenteral availability of EOC has been oxytocic drugs recognized as a key intervention c. Administration of parenteral antito reduce maternal mortality convulsants (Islam MT et al. 2005). The d.Manual removal of the placenta government of Bangladesh has e. Manual removal of retained fostered successful partnership products (e.g., manual/ vacuum with development agencies, aspiration) research institutions, and NGOs f. Assisted vaginal delivery in order to improve quality and g. Caesarean section delivery availability of EOC services across h.Blood transfusion Basic EOC comprises functions a-f the country. Various donorsupported programmes have focused on building capacity to strengthen EOC functions in the public health sector since 1993. Moreover, the government of Japan agreed to equip 47 UHCs with comprehensive EOC and 179 UHCs with basic EOC. USAID has invested in communication and social mobilisation activities in areas where EOC services have become functional. Interventions The MOHFW, through the Directorate of Health Services and Directorate of Family Planning has implemented the EOC interventions nationwide through an integrated approach with the reproductive healthcare agenda. UNICEF has supported the Directorate of Health Services since 1993, and accelerated support in 2000 through implementation of the Women’s Right to Life and Health (WRLH) project. UNFPA supported the Directorate of Family Planning and the interventions started on pilot basis in one division in 1993. To avoid duplication of planned EOC services at facilities that were nearer but governed by two different arms of the ministry, programme activities began in Rajshahi division in 1993 with consensus building and strengthening of coordination between these two directorates.

32

UNICEF intervention – the WRLH project The Women’s Right to Life and Health (WRLH) project, a joint collaboration between the GoB, UNICEF and the Averting Maternal Death and Disability Programme at Columbia University, USA, was implemented throughout the country for reduction of maternal morbidity and mortality (UNICEF 2000). The project strategy is to strengthen all district hospitals and selected 120 UHCs to provide 24-hour comprehensive EOC services. Twenty-four facilities in 14 districts were selected for the first year, based on a framework that draws on the number of deliveries conducted per year in the district hospital. The project has adopted the ‘three delays model’ (Maine 1997) as the basis for programmatic action to establish EOC and increase utilization of available services. It is based on a conceptual framework of three elements required for successful and ethical implementation of the programme - quality technology, management excellence and respect for human rights. The linkage between women’s status and maternal mortality has been popularized and the issue is being addressed as a woman’s right (UNICEF 1997). This means nurturing a socio-cultural movement that addresses the reduction of maternal mortality as a woman's right and also enhances women's self-esteem and status. Intervention Major intervention components include needs assessment, minor renovation of facilities, development of human resources (medical officer, nurse and laboratory technician), and Key intervention strategies supplying necessary equipments and logistics. To strengthen the manage- ¾ Providing 24-hour quality ment information system (MIS), the EOC services project introduced delivery, operation- ¾ Championing women's rights in the facility theater and obstetric registers (unified MIS register) at all the designated ¾ Building and sustaining accountability in the health facilities including MCWCs and medical facility college hospitals. Relevant persons were ¾ Building stakeholder trained on unified MIS register for accountability to reduce record-keeping and reporting in a maternal deaths prescribed format. The monthly MIS ¾ Mobilizing family and report from all project facilities are sent community accountability to the MIS section of the Directorate of to saving women's lives ¾ Measuring progress Health Services. according to the values and principles of the project Providing health education in the community is a routine activity of field staff. Health education mainly focused on the five danger signs, ANC, PNC and information on services available at the facilities. Community

33

and social mobilization activities included future search conference, observation of safe motherhood day, distribution of posters and leaflets, and strengthening of facility-based health education. Initiative was also taken to develop local level planning (micro planning) either through Appreciative Inquiry or Hospital Action Plan. The appreciative inquiry is a participatory (involving all the hospital staff and stakeholders) planning process based on local resources, providers’ needs and clients’ rights to improve quality of EOC services. It helps the facility staff envision a collectively desired future and to implement that vision successfully into reality. Hospital action plan is a 5-step process to develop a facility-based action plan to improve quality of care involving the key hospital staff. UNICEF has developed a five-step micro planning process called hospital action plan (HAP) to reach more facilities in a shorter time, while paying attention team building and details of 24-hour EOC readiness. In contrast to using appreciative inquiry the HAP uses self-assessment to improve individual performance and capacity of emergency response. It was conducted in 71 facilities by the end of 2003. The 5-step process includes assessment of ones knowledge and skills; room-to-room readiness and set-up of emergency action; preparation of a plan of action; allocation of responsibilities; and monthly team review (UNICEF 2004). A technical support system was established nationwide to facilitate implementation activities and monitoring of all project activities, and to check the unified MIS register for consistency of record keeping and reporting. UNFPA intervention

Barriers in EOC utilization

UNFPA supports the Directorate of Family Planning to establish 24-hour comprehensive EOC services at 64 MCWCs throughout the country. Interventions are similar to those of the WRLH project except for the development of facility-based micro plans – works in different facilities (Gill and Ahmed 2004). The MOHFW first implemented services in Rajshahi division of the country and later scaled up gradually to include all the MCWCs nationally. By 2003, all 64 MCWCs have completed the upgradation of services.

x Inconsistent cooperation between MCWCs and district hospitals x Non-availability of trained human resources and supplies (drugs & equipments) in DH, MCWC and UHC, x Most of the DH, MCWC and UHC lack facilities for D & C, blood transfusion and storage, general anesthesia and drugs, x Tremendous cost for services, x Lower status of women in the society often led them lack decision making power, x Poverty, x Distance and lack of transport facilities.

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CARE intervention The Dinajpur Safe Motherhood Initiative by CARE Bangladesh under NSDP was designed to test the impact of several interventions on use of obstetric services in government health facilities in Northwester Bangladesh during 1998-2001. The project undertook activities to improve the quality of care in the facilities included team-building among providers, case review and a stakeholder’s committee. CARE introduces a community mobilization intervention encompassing birth planning community support system for funding, transportation, blood donation for care of women with complications Health system linkages Staff from the MCWCs and district hospitals were encouraged to maintain close links with both higher and lower level health facilities to encourage referral of cases that could not be managed at a given level. A joint letter from the Directorate of Health Services and the Directorate of Family Planning was issued to encourage cooperation among the staff of MCWCs and district hospitals. District and upazila level managers were involved in promoting links between lower level facilities and the MCWCs as a first referral centre for STI and obstetric emergencies. Links were also made between government and project staff and local and international NGOs working in the area to coordinate coverage of services, transport arrangement and community awareness building activities. In addition, ambulances were provided to MCWCs that did not have one. Coverage Comprehensive EOC is available in 60% of the district hospitals, 27% MCWCs and 3% UHCs. Similarly, basic EOC is available in 14% district hospitals, 19% MCWCs and 32% UHCs. The coverage of EOC services has increased from 1 facility per 3.6 million populations in 1994 to 1 facility per 1.9 million populations in 1999 (UNICEF 2000). In southwestern Bangladesh, there were 1.04 and 0.64 comprehensive and basic EOC facilities respectively per 500,000 population. When compared with the baseline data, the coverage of comprehensive EOC facilities was found to be substantially increased from 0.23 to 6.9% (2006), which achieves the minimum UN standards but the coverage of basic EOC services remained the same (Islam et al. 2005, APR 2007). Achievements so far The availability and utilization of EOC services in Bangladesh has been assessed based on internationally recognized process indicators (UNICEF 1997) through surveys conducted in 1994, 1999 and 2002. Comparison to the baseline status of the project, the situation of UN Process

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Indicators shows considerable progress in Bangladesh with the exception of blood transfusion (UNICEF 2006, Hossain and Ross 2006, Gill and Ahmed, 2004). The use has doubled during 1994-2002, births in EOC facilities has increased by 63%, the number of complications treated in facilities increased by 135%, and the number of caesarean sections increased by 70%. As part of a national initiative assisted by UNICEF, 123 EOC facilities were equipped with operating theatres. From 1999 to 2002, births at the facilities increased by more than 25%, the number of women admitted with birth complications increased by almost 90% and the number of caesarean sections increased by more than 40% (UNICEF 2006). The differences in availability and use are due to differences in geographical location. By their nature comprehensive EOC facilities are typically located in urban areas, and not surprisingly, the availability of EOC tends to be better in capital cities than in the country overall (Paxton et al 2006). In south-western Bangladesh, the met need has increased by 24% in intervention area compared to 13% in comparison area and no changes were observed in the control area (Hossain and Ross 2006). Percentage of total births in facilities also significantly increased to 20.4% in 2001 from 8.3% in 1999 (p